Unconventional Candour

by George Smitherman

  Air ambulance announcement at Sunnybrook, with crew members and Dr. Chris Mazza.

  Looking back, I don’t see Ornge as a mistake. And it was certainly not a scandal. The story of the progress in the air ambulance service has been lost in all the foofaraw about Mazza and Ornge. Ontario now has one of the best-evolved models for air medical transportation in the world. Why not leverage it? As for the criticism from the left (notably CUPE) that we “privatized” the service, the opposite is true: we took it back from the hands of a private company (Canadian Helicopters). I did agree to allow Ornge to take on debt in order to purchase new helicopters and planes. That was not a radical step; hospitals have the same authority. The model was a good one. But Mazza took that model and manipulated it to his own benefit.

  Subsequently, after I had left the government, Mazza set up a web of for-profit spinoff companies, and the trouble began. What followed was a dubious deal with an Anglo-Italian helicopter manufacturer and a questionable payment to a Brazilian law firm, along with an allegation that Mazza had promoted his girlfriend to the position of associate vice-president at Ornge. All this ended up in the media, especially the Toronto Star, which made it into a crusade.

  A major point of contention was Mazza’s overall salary, which he had managed to keep a secret thanks to Ornge’s complicated public/private hybrid status. The government was hammered on this point day after day in the Legislature. Deb Matthews, by then minister of health, said she was unable to obtain the salary information because Ornge was “stonewalling” her. If I had been minister, I would have just called in the chair of Ornge and demanded an answer, or else I would have darkened the doorway of Mazza’s office unannounced until a satisfactory response was forthcoming.

  I was just a private citizen by this time, but I was so exasperated by Matthews’s response that I picked up the phone and called Mazza myself to ask him how much he was making. When he gave me the answer ($1.4 million), I was gobsmacked. That was roughly DOUBLE what the CEOs of the province’s largest hospitals were making. “That’s crazy,” I said. “I’m never talking to you again.” And I haven’t.

  There has been lots of speculation about why Mazza went off the rails like this. My theory is that he was deeply shaken by the death of his fourteen-year-old son in a skiing accident and, quite simply, lost his perspective. Indeed, after he was fired by the government, he checked into Guelph’s Homewood Health Centre to be treated for post-traumatic stress disorder. Looking back, I think perhaps I should have paid more attention to Mazza’s personal issues. I could get angry, but mostly I just get sad.

  But the management responsibility did not rest with Mazza alone. Ornge had a board of directors that included some distinguished Ontarians. The chair was Rainer Beltzner, also chair of Humber College. He signed off on Mazza’s salary and he knew how it dwarfed the salary that the president of a large community college was pulling down. I contend that Beltzner and his fellow directors were asleep at the switch and failed at their fiduciary responsibilities. They would have been the target of much more criticism if accountability had been doled out in an impartial rather than political setting.

  Where were the minister’s political staff and the ministry staff during those hundreds of days of stonewalling over Mazza’s salary? Did it not come to any of their minds that swift changes to the regulations or a hiccup in transfer payments to Ornge could have shifted the balance of power in the relationship?

  I accepted responsibility for not taking into account every eventuality when I handed Mazza the reins of Ornge. “I didn’t see it coming,” I told reporters after speaking to the all-party legislative committee probing the Ornge affair in 2012. “For the rest of my life, I will regret that.” Perhaps I gave Mazza too much licence. But most of the bad stuff happened long after I left the ministry. The critics said the excesses were made possible because of deficiencies in the legislation creating Ornge. But had I remained as health minister and the deficiencies had become apparent, I would have acted. Does anyone seriously think Chris Mazza would pull in $1.4 million a year while I was minister and get away with telling me to fuck off if I asked him about it?

  Still, my former colleagues in the government were all too happy to shift the blame to me. Their collaboration in the Boxing Day (2011) massacre column by Martin Regg Cohn of the Star was breathtaking. Citing government sources, Cohn wrote of me: “It’s not that everything he touched turned to dross; he merely left a mess behind for others to clean up.” That was my first real visit under a bus, although as the son of a truck driver I have been under many a truck in my day.

  Today, Ornge is just a brand, used as a sort of drive-by political slur in Ontario politics. A failed symbol of some kind. Screw that, I say. When I see a modern rotor- or fixed-wing Ornge aircraft above, I know it is on a flight of mercy, carving precious minutes on the way to saving lives. I know, too, that the service we have now in Ontario is more public, more integrated, and more capable than the fragmented, privately manipulated one I inherited in 2003.

  * * *

  What are the lessons here? First of all, arm’s-length agencies can cause trouble for governments because they are free from the usual oversight mechanisms for public spending. They are launched with good intentions as vehicles to get things done at a faster pace than the ponderous machinery of government normally operates. But the salaries they pay and expenses they file and contracts they let often become ingredients for the opposition and the media to cry “scandal.” There is no easier story to tell than one where people apparently take advantage of a situation to enrich themselves or their friends. Does that mean we should never create such agencies? No. They can be essential to progress in the public sector. But governments should always keep in mind the potential for them to backfire.

  Secondly, we have a problem with the various bodies that report directly to the Legislature, not the government — the auditor general, ombudsman, privacy commissioner, and so on. They have become sort of a cottage industry, competing with each other for headlines. And the quickest way to a headline is to throw out a number like $1 billion, no matter how far back one has to reach to get there. In both the eHealth and Ornge cases, the auditor general let stand, even if he didn’t utter it in the first place, the notion that $1 billion and $640 million, respectively, were either unaccounted for or simply wasted. This despite the fact that in both cases almost every penny of the allocated money was spent in the intended way, if imperfectly. To say it was all wasted is a gross exaggeration. But that was the impression left by the auditor general. Ironically the very officer paid to provide a sense of value for money to Ontarians ripped them off.

  I think governments are partly to blame for this, given their institutional instinct to keep everything confidential even where this is no material risk in its transparent release. That gives power to others who work in secret. I remain convinced that much more value-for-money analysis could come from eagle-eyed researchers and intrepid citizens if they were given greater access to government data. Instead, we have legislative officers duelling for headlines and reverting to tactics like leaking to get them. It is fair to treat their reports with far greater skepticism than before. Of course the media and opposition make much hay in the telling of scandal and anyone being criticized is naively advised if they think it’s all going to come out impartially.

  * * *

  Of late I have gotten a bit tired trying to educate people about what really happened with eHealth and Ornge, so I just say: “If you really think I blew $1.64 billion, then at least give me credit for the $3 billion–plus I saved the government in drug-purchasing expenses and the untold billions more in savings from diminishing annual hospital bailouts.”

  If you ask me, the real scandal of my time as minister of health was my delay in making rates of C. difficile in hospitals publicly reportable. Despite moving sooner on this than most jurisdictions, I wonder until today whether lives at Joseph Brant Hospital in Burlington might have been saved had I been less polit
ically defensive.

  CHAPTER SIX

  Health Reform

  During my time as minister of health, I prominently displayed a picture of Tommy Douglas in my Hepburn Block office. I was paying homage to Douglas’s role as the father of medicare in our country. But I was also acknowledging his local presence, for there is a housing co-op named after him on River Street in my riding. And Tommy’s daughter, Shirley, was also living in my riding, practically across the street from Queen’s Park. Each served as local reminders of his incredible legacy in our country.

  The fact remains, however, that the model of public health care that we adopted fifty years ago fell far short of the model that was originally advocated by Douglas. Specifically, there was inadequate support for community care. Today, medicare (what we call OHIP in Ontario) is badly in need of a remake that saves us from the “doctors and hospitals” funding preference. The truth is that, for all the talk about the transition to community care, it is being funded by incremental table scraps while the legacy health care system (doctors and hospitals) gobbles up most of the available dough.

  In a constrained environment with various demographic pressures threatening quality health care, I believe we must reset our priorities. We must stop encouraging patients to begin or renew their health care journeys with gatekeepers in the most expensive settings with the most costly providers. I call this a move away from “catch and release” toward “catch and care.”

  Late in 2017, Ontario announced $140 million in new funding as a so-called surge, but most of the new money was allocated to old solutions. Faced with 20 percent of regular hospital beds being occupied by patients who did not require that level (and cost) of care, Ontario announced plans to open more of the same. One wonders how many hours it will take to have all of that surge capacity eaten up before calls begin for the next surge? Did anyone other than hospital administrators get asked what they could do with $140 million to relieve the pressure of seniors seeking care?

  I have been told I was the most transformative health minister in a generation. As much as I believe that to be true, I have come to recognize that the forces against change (represented by the citizenry, society, press, and health care providers alike) make incrementalism feel like a transformation. Players inside the system celebrate increments that are unrecognizable to the untrained eye. And one thousand increments do not a transformation make, no matter how many times you use the word.

  If we really want to survive the twin statistical tsunamis of chronic disease and aging with some semblance of quality, then health care must be completely retooled and a new operating system installed. Only a monumental makeover will give us the system that the patients deserve and that our values and pride already project. After all, what is the purpose of living longer if we cannot also live better?

  Have no doubt, we are paying a price for our continued over-reliance — established at the outset of medicare — on hospitals and doctors. In the process, we have ignored solutions that could fundamentally reorient the gravitational pull of the Emergency Room, that 24/7 window to the most expensive care possible. Most damning is that those same high costs are often on a path toward the release of a high volume of at-risk patients back into the community. Meanwhile, we all remain smugly content that, if something goes awry, Mrs. Jones can always call 9-1-1.

  By being far more proactive in support of the needs of about 10 percent of the population, we could increase the mobility of health care professionals and replace $700 ambulance rides with $15 taxi fares.

  I am talking not just about more home care but also about a new kind of medicine to be practised in the hallways of Canadians’ homes. How about a system that recognizes the frail elderly and people with chronic disease or serious mental illness as our best customers and reduces their need and instinct to head to the ER? We could do that by allowing them to remain as “admitted” patients of the hospital even after they go home. Then they can enjoy the confidence that comes with having someone to call who knows their name. A number as convenient as 9-1-1. I have seen this hospital-in-the-home model at work in Sweden.

  In Ontario, St. Joseph’s Healthcare in Hamilton is the closest thing I have seen to a genuinely integrated system. That’s because St. Joe’s took an active interest in delivering care across all verticals of delivery, including community and home care. I don’t favour gutting the role of hospitals. Rather, I favour freeing up our hospital capacity and resources to deploy them more proactively as we look to reward providers for outcomes rather than for inputs.

  Canadians love their health care system, and rightly so; yet access issues, whether due to lack of resources or habit, create problems that are manifest when our health care outcomes are compared to those of our peers globally. According to report after report, there are two quality-crushing problems with our system, and both of those relate to wait times: namely, the wait to access primary care even if you have it, and the wait to have various specialty consultations and surgical procedures completed.

  I propose the following five reforms, which would improve quality within the current fiscal profile. They are audacious, ambitious, and revolutionary. But the change we need can only be accomplished if everybody recognizes his or her own power to contribute something to a universal benefit that has become a Canadian value. Revolutionary reforms, by their nature, ask a lot of everyone, not just some.

  Don’t get me wrong. Since serving as minister of health, I have been on the receiving end of health care, just like other Ontario families. And in respect of myself, my kids, my spouse, and my two aged parents, I have seen a range of exemplary care in a wide array of settings and in lots of hospitals.

  I have also experienced primary care in a family health team envir-onment, and two things are clear to me: if I need minor care, I can go unannounced and see a nurse who will, if necessary, immediately consult with others in the team, including nurse practitioners and doctors. And if my kids and I need care, we know the clinic hours and locations for each evening and weekend. All shots are administered by nurses. I rarely see my own doctor, who has known me well for some time. When I do see him, we review entries in my electronic health record and address new business. My son, who has ADHD and a learning disability, is a patient of a hospital that runs clinics with a precision that is both graceful and efficient. Continuous quality improvement seems to be the approach. And my mother, who suffered a brain aneurysm and a three-month decline, rapidly transitioned down the health care food chain from brain surgery at a University of Toronto–affiliated hospital to a restful death at home. Her death came just hours after coming home, where she was showered with love and supported with a lot of helpful facilitation by government-funded home-care providers (dare I say, they were profit oriented) organized seamlessly with the hospital discharge plan.

  Our family teamed up with those same home-care providers to keep my aging stepfather out of long-term care despite his eligibility. His final brief stay in hospital was facilitated by compassionate and skilled palliative care professionals as well as by bedside love from his family, and he passed two years and one day after my mother.

  So I have those personal stories and reflections. But I also know that the hardest thing for the Ontario health care system to get was that my mother and stepfather did not “go by” the stated names on their health cards. In a move down the hall from the ICU at one hospital, my mother Margaret’s identity was reset to Irene, her actual first name. I can’t get the picture out of my head of staff trying to get a rise out of my mother as her brain got foggier and foggier. “Irene! Irene! Irene!” And at another hospital, D’Arcy, the name my stepfather has been called since around the time of the Great Depression, was reset to Terrence, a name I’m not sure he would have recognized even in his prime.

  With the personal experiences noted here and my lengthy tenure running the largest government department in Canada, I want to offer my best ideas for reform. I should add the caveat that many people much smarter than me have
proposed solutions for health care, usually to accolades. But their proposals often lack common sense because they depend on impossible new political or constitutional deals. My solutions are smart insofar as they don’t play “nudge nudge, wink wink” with two-tier and other assaults on universality and the Canada Health Act. In fact, I see the Canada Health Act as helpful insofar as it prevents reforms that would threaten medicare’s underpinnings.

  Here are several things that people need to know if they are going to honestly appraise the solutions that I am proposing: 1) I believe in health care as a core service and a value of Canada that should be offered equitably and universally; 2) I believe that the framework of insured services should be as broad as possible; 3) I do not support models where preferential access to insured health care services is available to those who pay or use undue influence or live closer; 4) I believe that private health care is neither a natural-born threat nor a panacea for the delivery of health care; 5) I believe that an appropriate regulatory environment can be created to protect core values and expectations like quality; and 6) I think we should more openly acknowledge that much of what we cherish is already delivered privately, at the cost of billions annually, including long-term care, home care, laboratory and diagnostic services, and many physician services.

  Finally, I think it’s time to turn things upside down and leverage all of our community capacity before building more bricks-and-mortar institutional facilities. That is, we need to interrupt the cheery continuum that imagines everyone staying in a long-term care home for a time before their death. Also, hospitals are too big and too expensive to build and too costly to operate. We need to look for ways to shrink the building envelope and better leverage and develop other community infrastructure, starting with long-term care homes.